North Hills Collective - Participant Application Form

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***To be completed and signed by the parent or guardian and submitted to the North Hills Community Learning Center. Our funding source requires ALL the data below regarding income levels, residence and race. Forms will be maintained and kept confidential. (Child or Teen participants of the after school program and/or teen night program must be students of Upper Dublin School District in K-12th grade) ***

Date of application *

YYYY

Is your child a resident of North Hills Manor *

Yes

Does your child qualify for free/reduced lunch *

Yes

Child or Teen's Full Name (First, Middle, Last) *

Street Address *

City *

State *

Zip Code *

Child or Teen's date of birth *

YYYY

Child's current age *

Is your child... *

Female

Male

Name of school your child attends *

Grade (Sept 2023) *

Is your child Hispanic? *

Yes

Does your child have a disability? *

Yes

Child's race/ethnicity (select one) *

White

Black/African American

Asian

American Indian/Alaskan Native

Native Hawaiian/Other Pacific Islander

American Indian/Alaskan Native & White

Asian and White

Black/African American and White

Other/Multi-racial

Required

Father/Guardian Name (if not applicable, type N/A) *

Father/Guardian Phone # (if not applicable, type N/A) *

Mother/Guardian Name (if not applicable, type N/A) *

Mother/Guardian Phone # (if not applicable, type N/A) *

Emergency Contact Name & Relation *

Emergency Contact Phone # *

Parent/Guardian Email Address *

Is the parent/guardian a single head of household? *

Yes

If YES to the above question, the single head of household is:

Male

Female

Clear selection

Number of family members? (Family is all persons living in the same household who are related by birth, marriage, or adoption.) *

Based on your family size, into what category does your income fall? *

Moderate Income

Low Income

Very Low Income

Exceeds 2023 HUD Income Limits

I request that the student named above be considered for attendance at the North Hills Education & Recreation Program. He/she and I both agree to conform to all rules and regulations of the Program and the Center. We understand that any violation of these rules could lead to dismissal from the Program. I certify that the income information provided is true and accurate to the best of my knowledge and belief. Furthermore, I understand that by providing this certification of income that I will be asked to produce the documentation necessary to verify this income level. The verification may include pay stubs, IRS 1040 personal income tax forms, SSI, SSDI, etc. In addition, I give consent to the School District to share academic information about my child to this program to improve support. *

Yes

By typing your name here, you are signing the above statement. *

Submit

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